J Clin Med Res

Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc

Journal website http://www.jocmr.org

Original Article

Volume 11, Number 3, March 2019, pages 157-164

Status of Emergency Department Seventy-Two Hour Return Visits Among Homeless Patients

Figure 1. Time interval from ED index discharge to ED return cures using Kaplan-Meier survival analysis. (a) Time interval from ED index discharge to ED return curve comparisons between homeless patients and other (non-homeless) patients. (b) Time interval from ED index discharge to ED return curve comparisons among homeless patients with different classifications of ED utilization as determined by New York University ED Algorithm.

**Table 1.** General Information of Study Population
	Homeless patients (n = 5,926)	Non-homeless patients (n = 58,064)	P value
IQR: interquartile range; n: number; ESI: Emergency Severity Index; AMA: against medical advice; LWBS: left without being seen. ^aOthers including American Indian, Alaska Native, Asian, Native Hawaiian or other Pacific Islander, patient refused, or unknown.
Age, years, (median, IQR)	46 (36 - 55)	38 (27 - 51)	< 0.001
Sex, male, (n, %)	3,701 (62)	26,540 (46)	< 0.001
Race (n, %)			< 0.001
Caucasian	2,697 (46)	20,690 (36)
African American	2,857 (48)	19,283 (33)
Others^a	372 (6)	18,091 (31)
Ethnicity, Hispanic, (n, %)	441 (7)	16,988(30)	< 0.001
Insurance, yes, (n, %))			< 0.001
Private/commercial	103 (1.7)	5,675 (10)
Public/charity	4,413 (74)	25,994 (45)
No insurance	1,410 (24)	26,395 (45)
Mode of arrival (n, %)			< 0.001
Private vehicle	2,054 (35)	42,264 (73)
Healthcare assisted	2,636 (44)	12,964 (22)
Public/other transportation	1,236 (21)	2,836 (5)
Level of acuity (n, %)			< 0.001
ESI-1	26 (0.4)	484 (0.8)
ESI-2	909 (15)	8,714 (15)
ESI-3	3,352 (57)	36,425 (63)
ESI-4	1,388 (23)	11,031 (19)
ESI-5	233 (3.9)	1,266 (2.2)
Unclassified	18 (0.3)	144 (0.3)
History of alcohol abuse (n, %)	3,381 (57)	19,941 (34)	< 0.001
History of substance abuse (n, %)	2,891 (49)	10,339 (18)	< 0.001
History of psychiatric disorder(s) (n, %)	1,894 (32)	8,776 (15)	< 0.001
ED metrics
ED total length of stay, hours, (median, IQR)	4 (2 - 5)	4 (2 - 5)	< 0.001
ED disposition, yes, (n, %))			< 0.001
Discharge	5,376 (91)	54,879 (95)
AMA/eloped/LWBS	550 (9)	3,185 (5)
Primary care physician referral provided, yes, (n, %)	3,258 (55)	21,497 (37)	< 0.001
Medication prescribed at discharge, n, (median, IQR)	1 (0 - 2)	1 (0 - 2)	< 0.001
Return to ED within 72-h, yes, (n, %)	1,036 (17)	3,094 (5)	< 0.001

Table 1. General Information of Study Population

Homeless patients (n = 5,926)

Non-homeless patients (n = 58,064)

P value

IQR: interquartile range; n: number; ESI: Emergency Severity Index; AMA: against medical advice; LWBS: left without being seen. ^aOthers including American Indian, Alaska Native, Asian, Native Hawaiian or other Pacific Islander, patient refused, or unknown.

Age, years, (median, IQR)

46 (36 - 55)

38 (27 - 51)

< 0.001

Sex, male, (n, %)

3,701 (62)

26,540 (46)

< 0.001

Race (n, %)

< 0.001

Caucasian

2,697 (46)

20,690 (36)

African American

2,857 (48)

19,283 (33)

Others^a

372 (6)

18,091 (31)

Ethnicity, Hispanic, (n, %)

441 (7)

16,988(30)

< 0.001

Insurance, yes, (n, %))

< 0.001

Private/commercial

103 (1.7)

5,675 (10)

Public/charity

4,413 (74)

25,994 (45)

No insurance

1,410 (24)

26,395 (45)

Mode of arrival (n, %)

< 0.001

Private vehicle

2,054 (35)

42,264 (73)

Healthcare assisted

2,636 (44)

12,964 (22)

Public/other transportation

1,236 (21)

2,836 (5)

Level of acuity (n, %)

< 0.001

ESI-1

26 (0.4)

484 (0.8)

ESI-2

909 (15)

8,714 (15)

ESI-3

3,352 (57)

36,425 (63)

ESI-4

1,388 (23)

11,031 (19)

ESI-5

233 (3.9)

1,266 (2.2)

Unclassified

18 (0.3)

144 (0.3)

History of alcohol abuse (n, %)

3,381 (57)

19,941 (34)

< 0.001

History of substance abuse (n, %)

2,891 (49)

10,339 (18)

< 0.001

History of psychiatric disorder(s) (n, %)

1,894 (32)

8,776 (15)

< 0.001

ED metrics

ED total length of stay, hours, (median, IQR)

4 (2 - 5)

< 0.001

ED disposition, yes, (n, %))

< 0.001

Discharge

5,376 (91)

54,879 (95)

AMA/eloped/LWBS

550 (9)

3,185 (5)

Primary care physician referral provided, yes, (n, %)

3,258 (55)

21,497 (37)

< 0.001

Medication prescribed at discharge, n, (median, IQR)

1 (0 - 2)

< 0.001

Return to ED within 72-h, yes, (n, %)

1,036 (17)

3,094 (5)

< 0.001

**Table 2.** Comparison of 72-H Emergency Department Returns in Homeless Patients
	Homeless patients (n = 1,036)	Non-homeless patients (n = 3,094)	P value
IQR: interquartile range; n: number; AMA; against medical advice; LWBS: left without being seen; NYUA: New York University ED Algorithm; ESI: Emergency Severity Index. ^aOthers including American Indian, Alaska Native, Asian, Native Hawaiian or other Pacific Islander, patient refused, or unknown. ^bOthers including emergent/primary care treatable, emergent (ED care needed, preventable/avoidable), or unclassified one which referred to patients with injury, drug, psychiatric, or alcohol-associated ED visits.
Age, years (median, IQR)	46 (36 - 55)	42 (30 - 53)	< 0.001
Sex, male (n, %)	716 (69)	1,580 (51)	< 0.001
Race (n, %)			< 0.001
Caucasian	503 (49)	1,317 (43)
African American	476 (46)	1,047 (34)
Others^a	57 (5.5)	730 (24)
72-h ED returns			0.843
Related ED return (n, %)	749 (72)	2,227 (72)
Unrelated ED return (n, %)	287 (28)	867 (28)
Initial ED visit metrics
ED total length of stay, hours, (median, IQR)	4 (2 - 5)	4 (3 - 6)	< 0.01
ED disposition, yes, (n, %)			0.984
Discharge	907 (88)	2,708 (88)
AMA/eloped/LWBS	129 (12)	386 (12)
Primary care physician referral provided, yes, (n, %)	584 (56)	1,241 (40)	< 0.001
ED utilization determined by NYUA			< 0.001
Emergent care needed	365 (35)	1,179 (38)
Non-emergent care needed	251 (24)	651 (21)
Others^b	420 (41)	1,264 (41)
Return ED visit metrics
Return mode of arrival (n, %)			< 0.001
Private vehicle	275 (27)	1,759 (57)
Healthcare assisted	494 (48)	988 (32)
Public/other transportation	267 (26)	347 (11)
Return ED level of acuity (n, %)			< 0.001
ESI-1	9 (0.9)	35 (1.1)
ESI-2	193 (19)	634 (20)
ESI-3	547 (53)	1,795 (58)
ESI-4	220 (21)	495 (16)
ESI-5	63 (6.1)	129 (4.2)
Unclassified	4 (0.4)	6 (0.2)
Return ED Disposition (n, %)			< 0.001
No deviation in care	788 (76)	2,156 (70)
Significant deviation in care	151 (15)	722 (23)
Uncertain	97 (9.4)	216 (7.0)

Table 2. Comparison of 72-H Emergency Department Returns in Homeless Patients

Homeless patients (n = 1,036)

Non-homeless patients (n = 3,094)

P value

IQR: interquartile range; n: number; AMA; against medical advice; LWBS: left without being seen; NYUA: New York University ED Algorithm; ESI: Emergency Severity Index. ^aOthers including American Indian, Alaska Native, Asian, Native Hawaiian or other Pacific Islander, patient refused, or unknown. ^bOthers including emergent/primary care treatable, emergent (ED care needed, preventable/avoidable), or unclassified one which referred to patients with injury, drug, psychiatric, or alcohol-associated ED visits.

Age, years (median, IQR)

46 (36 - 55)

42 (30 - 53)

< 0.001

Sex, male (n, %)

716 (69)

1,580 (51)

< 0.001

Race (n, %)

< 0.001

Caucasian

503 (49)

1,317 (43)

African American

476 (46)

1,047 (34)

Others^a

57 (5.5)

730 (24)

72-h ED returns

0.843

Related ED return (n, %)

749 (72)

2,227 (72)

Unrelated ED return (n, %)

287 (28)

867 (28)

Initial ED visit metrics

ED total length of stay, hours, (median, IQR)

4 (2 - 5)

4 (3 - 6)

< 0.01

ED disposition, yes, (n, %)

0.984

Discharge

907 (88)

2,708 (88)

AMA/eloped/LWBS

129 (12)

386 (12)

Primary care physician referral provided, yes, (n, %)

584 (56)

1,241 (40)

< 0.001

ED utilization determined by NYUA

< 0.001

Emergent care needed

365 (35)

1,179 (38)

Non-emergent care needed

251 (24)

651 (21)

Others^b

420 (41)

1,264 (41)

Return ED visit metrics

Return mode of arrival (n, %)

< 0.001

Private vehicle

275 (27)

1,759 (57)

Healthcare assisted

494 (48)

988 (32)

Public/other transportation

267 (26)

347 (11)

Return ED level of acuity (n, %)

< 0.001

ESI-1

9 (0.9)

35 (1.1)

ESI-2

193 (19)

634 (20)

ESI-3

547 (53)

1,795 (58)

ESI-4

220 (21)

495 (16)

ESI-5

63 (6.1)

129 (4.2)

Unclassified

4 (0.4)

6 (0.2)

Return ED Disposition (n, %)

< 0.001

No deviation in care

788 (76)

2,156 (70)

Significant deviation in care

151 (15)

722 (23)

Uncertain

97 (9.4)

216 (7.0)

**Table 3.** Comparison of Risks Predictive of ED 72-H Returns in Homeless Patients
	Homeless patients adjusted hazard ratios	Non-homeless patients adjusted hazard ratios
CI: confidence interval; LL: lower limit; UL: upper limit; AMA: against medical advice; LWBS: left without being seen.
Sex (female)	0.72 (0.62, 0.84)	0.88 (0.82, 0.95)
Ethnicity (Hispanic)	0.96 (0.73, 1.25)	0.91 (0.83, 0.99)
Mode of arrival
Private vehicle	Reference	Reference
Healthcare assisted	1.54 (1.30, 1.82)	1.53 (1.40, 1.67)
Public/other transportation	1.62 (1.34, 1.97)	2.05 (1.79, 2.34)
Insurance
Commercial insurance	Reference	Reference
Public/charity insurance	1.58 (0.84, 3.00)	1.59 (1.37, 1.85)
No insurance	1.27 (0.67, 2.44)	1.10 (0.95, 1.29)
Primary care physician assigned (yes)	1.04 (0.90, 1.20)	0.86 (0.79, 0.94)
History of alcohol abuse (yes)	0.99 (0.85, 1.14)	1.37 (1.27, 1.49)
History of substance abuse (yes)	1.25 (1.08, 1.44)	1.39 (1.27, 1.52)
History of psychiatric disorder(s) (yes)	1.40 (1.22, 1.62)	1.50 (1.37, 1.64)
Initial ED disposition
Discharged	Reference	Reference
AMA/eloped/LWBS	1.57 (1.26, 1.94)	2.56 (2.27, 2.88)

Table 3. Comparison of Risks Predictive of ED 72-H Returns in Homeless Patients

Homeless patients adjusted hazard ratios

Non-homeless patients adjusted hazard ratios

95% CI (LL, UL)

CI: confidence interval; LL: lower limit; UL: upper limit; AMA: against medical advice; LWBS: left without being seen.

Sex (female)

0.72 (0.62, 0.84)

0.88 (0.82, 0.95)

Ethnicity (Hispanic)

0.96 (0.73, 1.25)

0.91 (0.83, 0.99)

Mode of arrival

Private vehicle

Reference

Healthcare assisted

1.54 (1.30, 1.82)

1.53 (1.40, 1.67)

Public/other transportation

1.62 (1.34, 1.97)

2.05 (1.79, 2.34)

Insurance

Commercial insurance

Reference

Public/charity insurance

1.58 (0.84, 3.00)

1.59 (1.37, 1.85)

No insurance

1.27 (0.67, 2.44)

1.10 (0.95, 1.29)

Primary care physician assigned (yes)

1.04 (0.90, 1.20)

0.86 (0.79, 0.94)

History of alcohol abuse (yes)

0.99 (0.85, 1.14)

1.37 (1.27, 1.49)

History of substance abuse (yes)

1.25 (1.08, 1.44)

1.39 (1.27, 1.52)

History of psychiatric disorder(s) (yes)

1.40 (1.22, 1.62)

1.50 (1.37, 1.64)

Initial ED disposition

Discharged

Reference

AMA/eloped/LWBS

1.57 (1.26, 1.94)

2.56 (2.27, 2.88)